CLINICAL SOCIETY MEETING R2

“SIMULTANEOUS GASTRIC AND ILEAL TRICHOBEZOARS CAUSING SMALL BOWEL OBSTRUCTION: A CASE REPORT’’ : 

“SIMULTANEOUS GASTRIC AND ILEAL TRICHOBEZOARS CAUSING SMALL BOWEL OBSTRUCTION: A CASE REPORT’’ PRESENTER Dr.S . LAL ( MS) ASSISTANT PROFESSOR DEPARTMENT OF SURGERY S.S.MEDIACL COLLEGE AND ASSOC. GM AND SGM HOSPITAL REWA

? WHAT IS TRICHOBEZOAR : 

? WHAT IS TRICHOBEZOAR The term bezoar comes from either the Arabic ‘badzehr’ or Persian ‘padzahr’ or Hebrian ‘beluzaar’ which all means antidote or counter poison. Bezoars were used as antidotes and as magical medicinal agents against plague, snake–bite, sexual weakness, leprosy and epilepsy by physicians from 12th to 18th century.

Slide 3: 

A trichobezoar is a mass of cumulated hair within the gastrointestinal tract, commonly collect in the stomach and fail to pass through the intestine. Trichobezoars usually result from trichotillomania (a behavioral disorder characterized by the compulsive urge to pull one’s hair) combined with trichophagia (the ingestion of hair).

Slide 4: 

The age of occurrence of bezoars from 1 to 56 years. The most common age between 15 and 20 years. More common in female.

CASE REPORT : 

CASE REPORT A 10-year-old girl presented to the surgery department in emergency hour with 3-days history of distention and pain in abdominal and bilious vomiting. She also complaining of epigastric lump since last one year.

Slide 6: 

Past History Her parents giving history of impulsive pulling and eating of one’s hair in early childhood, Which they felt resolved at 4 years of age.

Slide 7: 

On physical examination : The abdomen was tender Distended with visible bowel loops . Patient’s hair was normal with no visible alopecia.

Slide 8: 

Laboratory investigations showed anemia and leucocytosis.

Plane X –Ray Abdomen, Standing : 

Plane X –Ray Abdomen, Standing

Slide 10: 

Ultrasound Two separate masses; one adjacent to left lobe of liver and another in small -bowel was seen.

Provisional Diagnosis : 

Provisional Diagnosis Presenting Complain History Physical Examination Investigation: Routine X-Ray Ultrasound INTESTINAL OBSTRUCTION WITH ?TRICHOBEZOAR

Operative Procedure : 

Operative Procedure An exploratory laparotomy through an upper midline abdominal incision was performed.

Stomach Full with trichobezoar : 

Stomach Full with trichobezoar

Gastrotomy : 

Gastrotomy

Removal of trichobezoar : 

Removal of trichobezoar

After removal : 

After removal

Slide 18: 

. There was no extension of hair into the duodenum.

Rarity : 

Rarity One independent mass was palpated in the terminal ileum on further exploration of bowel. which was extracted through entrotomy.

Isolated ileal Trichobezoar : 

Isolated ileal Trichobezoar

Entrotomy : 

Entrotomy

Slide 22: 

Postoperatively the child recovered uneventfully. Psychiatric evaluation was done and found to be normal .

Discussion : 

Discussion Types Based on there composition Trichobezoars :commonest type of bezoar.(55%) Phytobezoars = plant and vegetable material such as orange pulp, celery, persimmon, pumpkin, and grass

Types : 

Types .Lactobezoars = precipitates of milk formula, usually in premature infants. Miscellaneous = trichophytobezoar (mixed), pharmacobezoar, mycobezoar or pseudobezor, persimmon fibers (diospyrobezoar).

Trichobezoar : 

Trichobezoar Trichobezoar is a complication of trichotillomania. Only half of the patients have a history of trichophagia . Laparosc Endosc Percutan Tech 2000;10:243-5.

In 5% of cases there may be more than one hair ball. : 

In 5% of cases there may be more than one hair ball. Primary intestinal trichobezoars without any associated gastric bezoars are uncommon and usually presents as an intestinal obstruction. The presence of discrete coexisting gastric and ileal trichobezoars are rare.

Gastrointestinal Trichobezoars : 

Gastrointestinal Trichobezoars Rapunzel syndrome :Trichobezoars extending continuously through the entire length of the small intestine as a tail. Vaughan et al. in 1968 .Surgery.1968;63:339-343.

IMAGINGS : 

IMAGINGS X-Ray: masse of opaque soft tissue in a swollen stomach and dilated small bowel. Both, the contrast radiography and the endoscopy of the upper GI tract are the diagnostic procedure of choice for establishing the diagnosis . Gastrointest Endoscop 2000;52:784-6. Ba : meal study- Gastrointestinal tricho.

.USG: Not pathognomic. It shows atypical curvilinear trichobezoar with bright echogenic band. : 

.USG: Not pathognomic. It shows atypical curvilinear trichobezoar with bright echogenic band. CT-scan : Non homogeneous, non–enhancing mass within the lumen of the stomach or bowel MRI: und to be better for both the site and the cause of small-bowel obstructions.

TREATMENT OPTIONS : 

TREATMENT OPTIONS SURGERY: Laparotomy or laparoscopy - the main stay of treatment. MINIMALLY INVASIVE SURGERY :Laparoscopic approach may be the treatment of choice for trichobezoar removal in the future. Singapore Med J 2007 ; 48 (2):e37-39

Treat. cont. : 

Treat. cont. . ENDOSCOPY :Small trichobezoar or fragmented into small pieces by Biopsy forceps, Polypectomy snares, foreign body forceps, Endoscopic injection of proteolytic enzymes , Water–jet spray, Lithotripter, Nd:YAG laser and Mechanical disimpaction.

Treatment cont. : 

Treatment cont. Chemical dissolution : with instillation of papain and sodium bicarbonate. Least success rate. For colonic trichobezoar, colonocopic evacuation.

Take Home message : 

Take Home message Trichobezoars are rare clinical entity. Stomach is the common site of occurrence. Primary intestinal trichobezoar are uncommon. The presence of discrete coexisting gastric and ileal trichobezoars are extremely rare. Various imaging modalities have been recommended for diagnosis.

Take Home Message : 

Take Home Message It is mandatory to perform a thorough exploration of all the small intestine and the stomach searching for retained bezoars (Satellite lesion). Surgery is mainstay of treatment (open /laparoscopic) Endoscopic removal of trichobezoars is difficult and risky, with minimal success rate. The cause of the trichophagia must be looked into.

Multidisciplinary approach : 

Multidisciplinary approach Radiologist, Pediatrician, Surgeons, Psychiatrics

Cont. : 

Cont. In any young girl, presenting with epigastric pain, vomiting and abdominal mass, trichobezoars should be considered as differential diagnosis. Psychiatric evaluation and follow-up are essential to treat any underlying behavioral illness that predisposes to recurrence.

“SIMULTANEOUS GASTRIC AND ILEAL TRICHOBEZOARS CAUSING SMALL BOWEL OBSTRUCTION: A CASE REPORT’’ : 

“SIMULTANEOUS GASTRIC AND ILEAL TRICHOBEZOARS CAUSING SMALL BOWEL OBSTRUCTION: A CASE REPORT’’ Lal S, Shukla P, Yedalwar V, Shrivastava GP. J Nepal Paedtr Soc 2011;31(1):72-74.

Thank You : 

Thank You